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Objective: Racial and ethnic minority enrollees in Medicare Advantage (MA) plans tend to be in lower-quality plans, measured by a 5-star quality rating system. We examine whether differential access to high-rated plans was associated with this differential enrollment in high-rated plans by race and ethnicity among MA enrollees. Data Sources: The Medicare Master Beneficiary Summary File and MA Landscape File for 2016. Study Design: We first examined county-level MA plan offerings by race and ethnicity. We then examined the association of racial and ethnic differences in enrollment by star rating by controlling for the following different sets of covariates: (1) individual-level characteristics only, and (2) individual-level characteristics and county-level MA plan offerings. Data Collection/Extraction Methods: Not applicable Principal Findings: Racial and ethnic minority enrollees had, on average, more MA plans available in their counties of residence compared to White enrollees (16.1, 20.8, 20.2, vs. 15.1 for Black, Asian/Pacific Islander, Hispanic, and White enrollees), but had fewer number of high-rated plans (4-star plans or higher) and/or more number of low-rated plans (3.5-star plans or lower). While racial and ethnic minority enrollees had lower enrollment in 4-4.5 star plans than White enrollees, this difference substantially decreased after accounting for county-level MA plan offerings (-9.1 to -0.5 percentage points for Black enrollees, -15.9 to -5.0 percentage points for Asian/Pacific Islander enrollees, and -12.7 to 0.6 percentage points for Hispanic enrollees). Results for Black enrollees were notable as the racial difference reversed when we limited the analysis to those who live in counties that offer a 5-star plan. After accounting for county-level MA plan offerings, Black enrollees had 3.2 percentage points higher enrollment in 5-star plans than White enrollees. Conclusions: Differences in enrollment in high-rated MA plans by race and ethnicity may be explained by limited access and not by individual characteristics or enrollment decisions. KEYWORDS access to care, health disparity, high-quality plan, Medicare Advantage, race, traditional Medicare, 1 | INTRODUCTION Enrollment in Medicare Advantage (MA), the segment of the Medicare program run by private insurance companies receiving capitated payments from the government, has been increasing over the [...]

Objective: To compare the outcomes of postacute care between home health (HH) and skilled nursing facilities (SNFs) following hospitalization among Medicare beneficiaries with a diagnosis of dementia. Data Sources: 100% MedPAR data, Minimum Data Set, and Outcome and Assessment Information Set assessment data from January 1, 2015 to December 31, 2016. Study Design: Retrospective cohort analysis using an instrumental variable design to compare outcomes (30-day readmission and mortality, 100-day mortality) of HH versus SNF following acute hospitalization. We used the differential distance between patients' home and the closest HH agency and SNF to instrument for nonrandom allocation of patients. Data Collection/Extraction Methods: We identified hospital discharges followed by SNF and HH stays for Medicare fee-for-service beneficiaries with dementia. We excluded beneficiaries younger than age 65, admitted to the hospital from a nursing home, or enrolled in hospice. We identified dementia using validated diagnostic codes with a 3-year look-back. Principal Findings: Our sample included 977,946 beneficiaries with a diagnosis of dementia; 297,732 (30.4%) received HH, while 680,214 (69.6%) went to SNF. Overall, 16.8% were readmitted to the hospital and 6.1% died within 30 days, while 15.4% died within 100 days of hospital discharge. In the instrumental variable analysis, there were no differences in any outcome between the two postacute care settings. Conclusions: Medicare beneficiaries with a diagnosis of dementia receiving postacute care in HH or SNF experienced similar rates of readmission and mortality across settings. This finding raises important questions about current postacute care referral patterns, given 7 in 10 patients with a diagnosis of dementia in our sample were discharged to SNF. KEYWORDS dementia, health policy, home health, postacute care, skilled nursing facility What is known on this topic * The prevalence of dementia and of postacute care use is rising in the United States. * No studies have compared outcomes of different postacute care settings for patients with dementia even though they vary significantly on cost and services provided. What this study adds * Medicare beneficiaries with a diagnosis of dementia receiving HH care had similar rates of hospital readmission and mortality to those receiving care in a SNF. * This finding raises questions about the appropriateness of postacute care referral patterns in beneficiaries without a diagnosis of dementia (where 50% of postacute care use is in SNF) and in beneficiaries with a diagnosis of dementia (where 70% of postacute care use in this sample is in SNF)., 1 | INTRODUCTION Currently, more than 40% of Medicare beneficiaries receive postacute care in a skilled nursing facility (SNF) or from a home health (HH) agency after hospital discharge, for [...]

Objective: To investigate the impact of Medicare's skilled nursing facility (SNF) co-payment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs. Data Sources and Study Setting: Retrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee-for-service beneficiaries. Study Design: We first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment. Principal Findings: From 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1-day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4-1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8-1.0), lower total Medicare payment for the 90-day episode after hospital discharge ($396; 95% CI 361-431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149-210, P < .001), offsetting the lower payment for the shorter index SNF stay. Conclusions: Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes. KEYWORDS Medicare payment, postacute care, skilled nursing facility, 1 | INTRODUCTION Use of skilled nursing facilities (SNFs) for postacute care is common and costly. Institutional postacute care incurs enormous costs to Medicare (1) and is a large contributor [...]

Objective: To measure the association between clinician specialization in nursing home (NH) practice and outcomes of patients who received postacute care in skilled nursing facilities (SNFs). Data Sources: Medicare claims and NH assessments for 2 118 941 hospital discharges to 14 526 SNFs in January 2012-October 2014 and MD-PPAS data for 52 379 clinicians. Study Design: Generalist physicians and advanced practitioners with > 90 percent of claims for NH-based care were considered NH specialists. The primary clinician during each SNF stay was determined based on plurality of claims during that stay. We estimated the effect of being treated by a NH specialist on 30-day rehospitalizations, successful discharge to community, and 60-day episode-of-care Medicare payments (Parts A and B). All models included patient demographics, clinical variables, and SNF fixed effects. Principal Findings: Nursing home specialists' patients were less likely to be rehospitalized (14.71 percent vs 16.23 percent; adjusted difference, -1.51 percent, 95% CI -1.78 to -1.24), more likely to be successfully discharged to community (56.33 percent vs 55.49 percent; adjusted difference, 0.84 percent, 95% CI 0.54 to 1.14), but had higher 60-day Medicare payments ($31 628 vs $31 292; adjusted difference, $335; 95% CI $242 to $429). Conclusions: Clinicians who specialize in NH practice may achieve better postacute care outcomes at slightly higher costs. KEYWORDS care quality, hospitalization, nursing home, postacute care, specialization, 1 | INTRODUCTION One in five Medicare beneficiaries discharged from the hospital receives postacute care in nursing homes (NH), or skilled nursing facilities (SNFs), which provide nearly half (47 percent) [...]

Objective. To test for differences in patient outcomes when hospital and post-acute care (PAC) providers participate in accountable care organizations (ACOs).Data/Setting. Using Medicare claims, we examined changes in readmission, Medicare spending, and length of stay among patients admitted to ACO-participating hospitals and PAC providers.Design. We compared changes in outcomes among patients discharged from ACO-participating hospitals/PACs before and after participation to changes among patients discharged from non-participating hospitals/PACs over the same time period.Results. Patients discharged from an ACO-participating hospitals and skilled nursing facilities (SNF) had lower readmission rates (--1.7 percentage points, p-value = .03) than before ACO participation and non-participants; and lower per-discharge Medicare spending (--$940, p-value = .001), and length of stay (--3.1 days, p-value Conclusions. Hospital and SNF participation in an ACO was associated with lower readmission rates, Medicare spending on SNF, and SNF length of stay. These results lend support to the ACO payment model.Key Words. Post-acute care, hospitals, accountable care organizations, Medicare, By creating incentives to manage the health of their members across health care settings, accountable care organizations (ACOs) have the potential to induce providers to work together to improve coordination [...]

In recent years, there has been substantial policy interest in the relationship between acute and postacute care providers and patients' transitions between them. This focus was precipitated by growing recognition [...]

Value-based purchasing programs seek to incentivize clinical quality improvement by linking providers' performance on key quality measures to financial penalties and rewards. Despite mixed evidence on their effectiveness at improving [...]

Objective. Performance thresholds are commonly used in pay-for-performance (P4P) incentives, where providers receive a bonus payment for achieving a prespecified target threshold but may produce discontinuous incentives, with providers just below the threshold having the strongest incentive to improve and providers either far below or above the threshold having little incentive. We investigate the effect of performance thresholds on provider response in the setting of nursing home P4P. Data Sources. The Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) datasets. Study Setting and Design. Difference-in-differences design to test for changes in nursing home performance in three states that implemented threshold-based P4P (Colorado, Georgia, and Oklahoma) versus three comparator states (Arizona, Tennessee, and Arkansas) between 2006 and 2009. Principal Findings. We find that those farthest below the threshold (i.e., the worst-performing nursing homes) had the largest improvements under threshold-based P4P while those farthest above the threshold worsened. This effect did not vary with the percentage of Medicaid residents in a nursing home. Conclusions. Threshold-based P4P may provide perverse incentives for nursing homes above the performance threshold, but we do not find evidence to support concerns about the effects of performance thresholds on low-performing nursing homes. Key Words. Performance-based thresholds, quality of care, pay-for-performance, nursing home quality, long-term care, The use of pay-for-performance (P4P) to improve health care quality has become commonplace in the United States. Despite the proliferation of P4P programs, there is mixed evidence to support their [...]

Objective. Limited consumer use of health care report cards may be due to the large amount of information presented in report cards, which can be difficult to understand. These limitations may be overcome with summary measures. Our objective was to evaluate consumer response to summary measures in the setting of nursing homes. Data Sources/Study Setting. 2005-2010 nursing home Minimum Data Set and Online Survey, Certification and Reporting (OSCAR) datasets. Study Design. In December 2008, Medicare converted its nursing home report card to summary or star ratings. We test whether there was a change in consumer demand for nursing homes related to the nursing home's star rating after the information was released. Principal Findings. The star rating system was associated with a significant change in consumer demand for low- and high scoring facilities. After the star-based rating system was released, 1-star facilities typically lost 8 percent of their market share and 5-star facilities gained over 6 percent of their market share. Conclusions. The nursing home star rating system significantly affected consumer demand for high- and low-rated nursing homes. These results support the use of summary measures in report cards. Key Words. Quality of care, public reporting, quality measures, nursing home, Health care 'report cards' are designed to improve the performance of health care markets by enabling consumers to identify and choose high-quality providers and, by making demand more elastic to [...]

Objective. To evaluate the perceived usefulness of publicly reported nursing home quality indicators. Study Setting. Primary data were collected from October 2013 to August 2014 among a convenience sample of persons (or family member) recently admitted or anticipating admission to a nursing home within 75 miles of the city of Philadelphia. Study Design. Structured interviews were conducted to assess the salience of data on the Medicare Nursing Home Compare website, including star ratings, clinical quality measures, and benchmarking of individual nursing home quality with state and national data. Data Collection. Interviews were transcribed verbatim, independently coded by two reviewers, and agreement determined. A thematic analysis of transcripts was undertaken. Principal Findings. Thirty-five interviews were completed. Eighty-three percent (n = 29) were caregivers and 17 percent (n = 6) were residents. Star ratings, clinical quality measures, and benchmarking information were salient to decision making, with preferred formats varying across participants. Participants desired additional information on the source of quality data. Confusion was evident regarding the relationship between domain-specific and overall star quality ratings. Conclusions. The Nursing Home Compare website provides salient content and formats for consumers. Increased awareness of this resource and clarity regarding the definition of measures could further support informed decision making regarding nursing home choice. Key Words. Nursing home, public reporting, quality indicators, In response to concerns about low quality of U.S. nursing homes (Institute of Medicine 1986; Wunderlich and Kohler 2000), the Centers for Medicare and Medicaid Services began publicly reporting nursing [...]

Objective. To evaluate the effect of medical home implementation on primary care delivery in the Veterans Health Administration (VHA). Data Sources/Study Setting/Study Design. We link interview-based qualitative data on medical home implementation to quantitative outcomes from VHA clinical encounter data. We use a longitudinal analysis with provider fixed effects (taking advantage of variation in timing of implementation and allowing each provider to serve as a control for him or herself) to test whether patient-aligned care team (PACT) implementation was associated with changes in organizational processes and patient outcomes. Principal Findings. Among 683 PCPs, caring for 321,295 patients, the uptake of eight of nine PACT structural changes significantly increased from July 2010 to June 2012 as did the percentage of primary care appointments occurring by telephone and hospital discharges contacted within 2 days of discharge. We found that PACT implementation was associated with significant improvements in 2-day post-hospital discharge contact, but not primary care visits occurring by telephone or within 3 days of the requested date. We found no association between medical home implementation and rates of emergency department use by patients. Conclusions. Medical home implementation at the VHA resulted in large changes in the structure of care but few changes in patient-level outcomes. These results highlight both the complexity of studying the effect of the medical home as well as implementing this model to change primary care delivery. Key Words. Medical home, veterans, primary care delivery, The patient-centered medical home has increasingly been looked to by policy makers, health care providers, and private insurers as a potential solution to the fragmented and inefficient U.S. health care [...]

Objective. Pay-for-performance (P4P) is commonly used to improve health care quality in the United States and is expected to be frequently implemented under the Affordable Care Act. However, evidence supporting its use is mixed with few large-scale, rigorous evaluations of P4P. This study tests the effect of P4P on quality of care in a large-scale setting--the implementation of P4P for nursing homes by state Medicaid agencies. Data Sources/Study Setting. 2001-2009 nursing home Minimum Data Set and Online Survey, Certification, and Reporting (OSCAR) datasets. Study Design. Between 2001 and 2009, eight state Medicaid agencies adopted P4P programs in nursing homes. We use a difference-in-differences approach to test for changes in nursing home quality under P4P, taking advantage of the variation in timing of implementation across these eight states and using nursing homes in the 42 non-P4P states plus Washington, DC as contemporaneous controls. Principal Findings. Quality improvement under P4P was inconsistent. While three clinical quality measures (the percent of residents being physically restrained, in moderate to severe pain, and developed pressure sores) improved with the implementation of P4P in states with P4P compared with states without P4P, other targeted quality measures either did not change or worsened. Of the two structural measures of quality that were tied to payment (total number of deficiencies and nurse staffing) deficiency rates worsened slightly under P4P while staffing levels did not change. Conclusions. Medicaid-based P4P in nursing homes did not result in consistent improvements in nursing home quality. Expectations for improvement in nursing home care under P4P should be tempered. Key Words. Quality of care, pay-for-performance, nursing home quality, long-term care, The use of pay-for-performance (P4P) to improve health care quality has become commonplace in the United States. P4P is based on the principle that provider payment should be determined by [...]

Objective. Quality measures may be associated with improved outcomes for two reasons. First, measured activities may directly improve care. Second, success on these measures may be a marker for other unmeasured aspects of high quality care. Our objective is to test the contribution of both possible effects. Data Sources. 2004 Medicare data on hospital performance from Hospital Compare and risk-adjusted mortality rates from Medicare Part A claims. Study Design. We studied 3,657 acute care U.S. hospitals and compared observed differences in condition-specific hospital mortality rates based on hospital performance with expected differences in mortality from the clinical studies underlying the measures. Principal Findings. Differences in observed mortality rates across U.S. hospitals are larger than what would be expected if these differences were due only to the direct effects of delivering measured care. Conclusions. Performance measures reflect care processes that both improve care directly and are also markers of elements of health care quality that are otherwise unmeasured. This finding suggests that process measures capture important information about care that is not directly measured, and that these unmeasured effects are in general larger than the measured effects. Key Words. Quality of care, quality improvement, performance measurement, process measures, Because measuring quality is seen as essential to improving it, quality is measured, and in many cases reported, for hospitals, health plans, nursing homes, home health agencies, and physicians. These [...]